This article is more than 5 years old. Information may no longer be current.
Does the world need authors or critics, if we have to choose?
(the increase in breast cancer, the USPSTF and the future)
Click Here to Manage Email Alerts
I have known for years that the government is here to help me, and I usually appreciate its presence.
One of its important roles is to keep an eye on our numbers — cancer stats, caseloads, efficiencies, income, expenditure, research funding, reimbursement for work, requirements to use electronic records and many other domains, more recently with a larger emphasis on quality and value.
I recently was troubled to hear the report at the American Association for Cancer Research Annual Meeting that the number of new patients who present with breast cancer is likely to increase 50% by 2030. It is not clear to me whether the majority of the new anticipated diagnoses will represent life-threatening cancers, or whether our testing approaches are becoming more sensitive — but less specific — and producing an echelon of more indolent, less aggressive “tumors” at the hinterland between the benign and malignant domains.
Derek Raghavan
Given what we know about gene expression, obesity and other risk factors for breast cancer, it is disturbing to think that some variant of breast cancer will continue to increase to such an extent, and it makes me wonder whether our colleagues in the world of cancer prevention are missing something important. I have always been surprised at the vast sums that Uncle Sam allocates for cancer prevention research when one considers what seem to be relatively modest paradigm-shifting outcomes during the past few decades, and I occasionally wonder if anyone actually looks at the bang for the buck in that field.
USPSTF recommendation
While on the topic of breast cancer, it seems that the government stepped into the ring again, courtesy of the U.S. Preventive Services Task Force (USPSTF), which apparently has felt the need to issue another draft encyclical for public distribution. This time, it seems to have backed down a little from its 2009 position but, unfortunately, reaffirmed its commitment to age 50 years as the lower end of the cutoff for routine mammography.
The task force’s overall stance could be summarized thus:
Of importance, the USPSTF “clarified” its 2009 encyclical thus: “A ‘C’ recommendation is not a recommendation against mammography screening in this age group; it denotes that there is moderate certainty of a small net benefit in the population. Rather, a C recommendation emphasizes that the decision to screen must be an individual one, made only after a woman weighs the potential benefit against the possible harms.”
This is a real problem. When it takes 6 years for a body like the USPSTF to clarify its extraordinarily opaque and confusing stance in the domain of public health, against a background of serious debate about that stance, something is really wrong! What is an intelligent and thoughtful woman supposed to conclude from this nonsense?
Limited experience, questionable evidence
When I review the composition of the USPSTF breast cancer panel, I don’t find a level of experience that should reasonably and repeatedly be challenging the equally evidence-based recommendations of several learned colleges and professional societies.
What really bothers me is that its stance has been controversial from the outset, and yet the USPSTF has not been able to mount additional data to support its views. For those of us who are actively responsible for doing something in the clinical space, and who expend time and resources trying to secure cooperation in screening activities from a confused — and increasingly doubtful — public, every public controversy becomes a nuisance and pushes women who may be cured as a result of screening away from this approach.
My second big concern is the nature of the evidence that it has leveraged. It seems a key component is the oft-heralded Canadian study by Miller and colleagues, which has certainly been roundly criticized. There is no doubt that the Canadians are masters of doing careful and thoughtful analytical studies of published data, and they often have the courage to take on tough, randomized trials — and take them to completion. Many of their studies — often led from the NCIC Clinical Trials Group — have been paradigm shifting, and have made us better oncologists and carers for patients. However, some of the criticisms of the Miller study do bear consideration.
In this large randomized trial, which has been extensively detailed, nearly 90,000 women aged 40 to 59 years were randomly assigned to serial mammograms with physical examinations vs. a physical examination followed by surveillance at the discretion of their own physicians. In the present context, issues of concern include the discordance with other randomized trials, the lack of rules or surveillance regarding off-study mammography, the entry criterion that allowed women with negative prior mammograms to enter the study, and assumptions regarding the potential for women in the control arm to secure their own mammograms off-protocol.
Surprisingly, the tumors that were detected by physical examination had a much higher prevalence of ER positivity than impalpable tumors, which may have influenced the outcome of their treatment and suggested the possibility of inadvertent case-acquisition bias. Although this was a large and well-conducted study, in general, the extant concerns make it surprising that it has had such an impact on the task force’s decision process.
A ‘puzzling’ effect
The impact of the USPSTF is puzzling to me. I view it as something of a nuisance, but that’s just a personal view. My biggest concern is that it has managed sequentially to muddy the waters regarding the utility of screening in several cancers for which those of us involved in clinical work have struggled to explain the broad and proven benefits of screening and early diagnosis.
Although I share its view that screening for prostate cancer is of unproven benefit — and may be harmful — for asymptomatic white males, it hasn’t inserted the appropriate caveats relating to African-Americans nor men with positive family histories, an important missed opportunity.
Despite adding confusion to the mix, it appears that its 2009 statement on breast cancer hasn’t had the desired effect. According to Dehkordy and colleagues, a recent survey showed a reduction in mammographic screening in 2010-2012 compared with 2007-2008, but without a significant impact on patterns in those aged 40 to 50 years; thus, it seems that it has potentially set the mission of screening back somewhat, and hopefully this will not translate in the next set of surveys into an increase in stage at presentation and death from cancer!
I don’t actually know the optimal approach to screening for breast cancer, and it is quite possible that the stance of the USPSTF is actually correct. The problem is the amount of damage being done to the public health efforts to encourage undereducated, impoverished and frightened people — who may or may not be at increased risk — to avail themselves of the resources that have been developed.
Based on controversial level one evidence — obfuscated by a series of post-hoc analyses and meta-analyses — the USPSTF has managed to add to the confusion of the populace, and it seems that it may be moving the women who really need to undergo routine mammography away from that potentially life-saving tool. That is wrong, and it is troubling that our government — despite the rhetoric and the distancing from this task force by many of our political leaders in the health space — seems to have done nothing about it.n
References:
Dehkordy SF, et al. Am J Prev Med. 2015;doi:10.1016/j.amepre.2015.02.017.
Miller AB, et al. BMJ. 2014;doi:10.1136/bmj.g366.
Nelson HD, et al. Screening for breast cancer: A systematic review to update the 2009 U.S. Preventive Services Task Force recommendation. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
Rosenberg PS, et al. Abstract 1850. Presented at: American Association for Cancer Research Annual Meeting; April 18-22, 2015; Philadelphia.
U.S. Preventive Services Task Force. Ann Intern Med. 2009;doi:10.7326/0003-4819-151-10-200911170-00008.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.